Successful Percutaneous Closure of Gerbode Defect and Right Atrial-Aortic Fistula Following Infective Endocarditis

We report a case of infective endocarditis with a septal abscess that was complicated with abnormal blood flow from the left ventricle to the right atrium (Gerbode defect) along with abnormal blood flow from the aorta to the right atrium (atrial-aortic fistula). This is the first reported case of successful correction of both defects by a percutaneous approach.

respiratory rate of 18 breaths/min.On examination, the patient had numerous palpable nonpruritic rash lesions on the bilateral lower extremities (left more than right) with sparing of the soles, his lungs were clear on auscultation, he had a regular heart rate without any murmur, no jugular venous pressure elevation was present, and he had no neurologic deficits.A complete blood count showed normal white blood cells, red blood cells, and platelets.
Other laboratory tests showed an elevated creatinine level of 1.50 mg/dL, and urinalysis results were unremarkable.The patient was admitted to the medical service for management of acute kidney injury.On day 2, he developed high-grade fevers.

PAST MEDICAL HISTORY
The patient had no known medical conditions, except that he had presented to the emergency department 2 weeks earlier with symptoms of a urinary tract infection and was empirically treated with cefalexin.

LEARNING OBJECTIVES
To recognize the clinical presentation, diagnostic approach, and management strategies for infective endocarditis complicated by a Gerbode defect and an RAAF.To understand the decision-making process and outcomes of transcatheter vs surgical interventions in high-risk cardiac patients.Given that RAAF is rare, limited evidence is available for its correction through the transcatheter approach; 3 however, there is a published report in which corrective measures were obtained by a surgical approach. 8,9For the Gerbode defect, the literature indicates a preference for surgical closure, thus providing a definitive solution by restoring normal cardiac anatomy.However, this approach poses various risks, including an operative risk, cardiac complications, pulmonary issues, postoperative bleeding, and thromboembolism, especially for a patient in shock and with fulminant heart and multiorgan failure. 10 contrast, scarce literature supports the transcatheter approach for Gerbode defect management. 3vertheless, the advantages of the transcatheter approach lie in being minimally invasive, avoiding sternotomy, enabling quick recovery, causing less impact on surrounding tissues, and resulting in a comparatively shorter hospital stay. 11Potential drawbacks include incomplete closure, new infections, device-related complications, and arrhythmias. 12,13e choice between transcatheter and surgical management hinges on factors such as concomitant comorbid conditions and surgeon and patient preferences.In our high-risk patient with concomitant defects, where redo surgery was not recommended, we successfully closed both defects by using a transcatheter approach.

FOLLOW-UP
The patient was seen in the clinic 2 weeks after discharge.At that time, his status was NYHA functional class I.The patient's condition was compensated with GDMT.

FUNDING SUPPORT AND AUTHOR DISCLOSURES
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

R E F E R E N C E S
ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2024.102410DIFFERENTIAL DIAGNOSIS Considering the lower extremity rash, a cephalexin-related skin reaction was the top differential diagnosis because cephalexin was the only medication the patient kept taking.However, his fatigue and weight loss were unexplained.INVESTIGATIONS With the episode of high-grade fevers, blood cultures were obtained, and the results revealed gram-positive cocci in chains that eventually were identified as Streptococcus anginosus group.A transthoracic echocardiogram revealed a large vegetation on the aortic valve.MANAGEMENT Intravenous (IV) vancomycin was started after receipt of positive culture results, and an infectious disease specialist was consulted.The patient did not show response to antibiotic therapy and remained febrile the following day.He eventually became confused, and that raised concern for a septic cerebral embolism.The patient was transferred to the intensive care unit.Cardiac magnetic resonance (CMR) showed punctate septic emboli to the left splenium of the corpus callosum, the right periventricular centrum semiovale, and the right subcortical right frontal lobe.The patient's hospital course was further complicated by bradycardia, which eventually progressed to complete heart block requiring placement of a temporary pacemaker.A transesophageal echocardiogram (TEE) revealed a large vegetation attached to the aortic valve and prolapsing into the LV outflow tract with evidence of severe anteriorly directed aortic regurgitation and possible communication between the aortic root and the right ventricular (RV) septum (Figures 1A and 1B and 2A and 2B, Videos 1 and 2).Cardiothoracic surgery was performed for aortic valve replacement and right atrial, RV, and aortic annular repair using a CorMatrix patch (Cor-Matrix Cardiovascular).Postoperatively, a dualchamber CMR-compatible pacemaker was inserted.After 12 days, the patient's condition improved, and he was eventually discharged to a rehabilitation facility to complete 6 weeks of IV ceftriaxone (2 g).Two weeks later, the patient was readmitted with acute heart failure and was found to have a new onset murmur, anasarca, and cardiogenic shock.The patient did not respond well to guideline-directed medical therapy (GDMT), and he was eventually

FIGURE 1
FIGURE 1 Transesophageal Echocardiographic Biplane Image at the Aortic Valve Level

FIGURE 4
FIGURE 4 Transesophageal Echocardiographic Image at the Midesophageal Long Axis With Color Flow Doppler Demonstrating Flow Between Right Coronary Cusp to the RA

FIGURE 6
FIGURE 6 Transesophageal Echocardiographic Short-Axis View at the Aortic Valve Level With Color Flow Doppler Showing Successful Closure of the Right Atrial-Aortic Fistula Figures 2 and 3.
Closure of Gerbode and Right Atrial-Aortic Defects Our case highlights the successful use of a transcatheter approach for a high-risk patient with a concomitant Gerbode defect and RAAF.Despite the traditional preference for surgical closure, our experience underscores the viability of individualized transcatheter strategies in complex cardiac scenarios.This case contributes to the evolving landscape of cardiac interventions and emphasizes the need for personalized patient care and ongoing research to refine transcatheter applications in diverse clinical contexts.